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Publication #FCS8996

Breast Cancer: Follow-up Care1

Martina Murphy, M.D., and Karen Daily, D.O.2

The last visit to the surgeon, oncologist, or radiation clinic is considered the end of active treatment for breast cancer. While often there is a sense of relief and accomplishment to have reached that milestone, the transition from active care to survivorship also brings increased responsibility for women to monitor their own health and to do what they can to stay healthy. Some women become more anxious than when they were first diagnosed. This fact sheet offers some information, guidance, and reassurance about what to expect in this next phase.

Managing Complications from Breast Cancer Treatment

Local Complications from Surgery/Radiation

Radiation and surgery can impair arm and shoulder movement. Exercise, massage, and physical therapy can help restore mobility and reduce pain. Radiation can cause fibrosis (or “scarring”) of tissues in the radiated field that may appear as thickened breast or chest wall skin. Rarely, radiation can cause damage to internal organs such as lungs or heart. Lymphedema, swelling in the arm, is a condition that sometimes occurs after surgery and/or radiation and is more likely if you have had multiple lymph nodes removed. Physical therapists knowledgeable in the treatment of lymphedema can help teach you proper care of your skin and arm to prevent or reduce swelling. Compression sleeves are available and can be helpful in the reduction of swelling.

Complications from Systemic Treatment

Systemic treatments are those administered by a medical oncologist and include chemotherapy, newer biologic therapies such as trastuzumab (Herceptin®), or antiestrogen tablets, also called endocrine or hormone treatment.

Heart Complications

Some systemic treatments can cause damage to the heart muscle. A class of chemotherapy drugs called anthracyclines—e.g., epirubicin, doxorubicin (Adriamycin®), and trastuzumab (Herceptin®)—can increase the risk of heart failure for years after treatment. This risk is increased in the presence of other common risk factors for heart failure such as uncontrolled hypertension, diabetes, obesity, and tobacco use. Let your physician know if you experience a cough, shortness of breath with exertion, or swelling in your feet and ankles as these can be signs of heart failure. For women who undergo chest radiation, it is important to be aware that this can lead to several types of cardiac complications including coronary artery disease, conduction problems resulting in heart rhythm abnormalities, and/or heart failure.

Sexual/Reproductive Functioning

Sexual and reproductive health can be compromised by breast cancer treatment. Decreased libido, vaginal dryness resulting from low estrogen levels, and issues related to body confidence all can contribute to a change in sexual function. Exercise improves libido and body confidence and can have a positive impact on sexual health and functioning.

Fertility also may be affected by breast cancer treatment. While menses often cease during treatment, many young premenopausal women regain menstruation within two years of completion of chemotherapy. It is important to understand that fertility and menses are not necessarily linked and you may still be fertile even if your menses do not return. Conversely, having a regular menstrual cycle after chemotherapy does not necessarily mean you are fertile. If you are interested in getting pregnant after treatment for breast cancer, you should consult with a physician who specializes in reproductive endocrinology to discuss your fertility options.

Bone Health

Aromatase inhibitors, or AIs, such as anastrozole (Arimidex®), letrozole (Femara®), and exemestane (Aromasin®) can cause loss of bone mineral density. Bone density testing should be performed when aromatase inhibitors are started and periodically thereafter. Women who have undergone premature menopause as a result of breast cancer treatment, such as surgical removal of the ovaries or chemotherapy-induced cessation of menses, will want to have their bone density evaluated as well. A calcium (500–600 mg) / vitamin D (400 IU) supplement once a day in addition to a healthful diet that includes good sources of calcium and vitamin D and a weight-bearing exercise regimen can help prevent excessive bone loss. There are prescription medications that can be used for women who have already experienced some loss of bone mineral density.

Mental Health

The diagnosis and treatment of breast cancer can be very stressful for patients and their families. Concerns about the financial implications of treatment related to medical expenses and loss of income contribute to the distress associated with the diagnosis itself. It is not uncommon to experience symptoms such as excess worry, difficulty sleeping, poor appetite, and exhaustion. Women experiencing depression and/or anxiety symptoms may benefit from counseling provided by a professional trained in the issues specific to cancer patients. This also can be beneficial for family or friends who are serving as caregivers. Exercise is very effective in dealing with symptoms of mild depression and/or anxiety. Sometimes prescription medications can be helpful.

Overall Well-being and the Importance of Positive Lifestyle Choices

Diet and Exercise

Commonly, women undergoing adjuvant chemotherapy unintentionally gain weight, on the average of about 15 pounds. One of the most important recommendations for breast cancer survivors is exercise, which decreases both the risk of breast cancer recurrence and the risk of developing a new breast cancer. Breast cancer risk in post-menopausal women is further reduced by avoiding obesity (BMI over 30) and exercise helps with weight control. Exercise also is one of the most effective ways to address the chronic fatigue and memory problems that many survivors experience. Breast cancer survivors are encouraged to engage in 30 to 60 minutes of vigorous aerobic exercise most if not all days of the week. There is no particular diet that a breast cancer survivor should follow other than the recommendations of the Dietary Guidelines for Americans (http://www.cnpp.usda.gov/dietaryguidelines.htm). Be sure to eat a diet that includes whole grains, colorful fruits and vegetables, a variety of lean protein sources, and low-fat/fat-free dairy, or other calcium- and vitamin D-rich foods.

Doctor Visits

The current expert recommendation (NCCN.org) is for follow-up every 4–6 months for 5 years after which you can see your doctor on a yearly basis. Some survivors transition their care to their primary care physician while others continue to be seen by their medical oncologist. Regardless of the type of physician caring for you, the following are important reminders:

  • Annual mammogram

  • Monthly breast self-exams and annual clinical breast exam

  • See your doctor promptly to discuss any new symptoms of concern.

  • Maintain a healthy lifestyle and aim to avoid excessive weight gain.

  • Exercise vigorously 30–60 minutes most if not all days of the week.

  • Consider taking a calcium / vitamin D over-the-counter supplement for bone health.

  • Refrain from using any form of tobacco.

  • If you choose to drink alcoholic beverages, limit intake to no more than 3–4 drinks per week.

Stay up to date on preventive care such as colonoscopy, Pap smear, blood cholesterol and blood pressure monitoring.

Checking for Recurrence and Metastasis

Part of your follow-up care will necessarily focus on checking for recurrence. It is important to understand the difference between local and distant recurrence of cancer.

Local recurrence refers to cancer that has returned in the previously treated breast, chest wall, or lymph nodes. Monthly self-exams and annual mammography are used to detect a return of breast cancer cells in the same place. These are also the methods by which a new breast cancer could be detected; breast cancer survivors are at increased risk for a second breast cancer.

Distant recurrence refers to cancer that appears in a different part of the body and is also called “metastasis.” The most common site for breast cancer metastasis is in bone, but it also can occur in the brain, liver, or lungs. Routine use of lab and radiographic studies are not recommended; however, promptly seeking medical care for any new or concerning symptoms so that appropriate testing can be ordered is the best course of action.

Symptoms to be aware of include:

  • A new or different pain that does not respond to conservative treatment

  • Numbness/weakness in a particular part of your body

  • Headaches, vision changes, confusion, nausea

  • Cough or shortness of breath

  • Loss of appetite and/or unintentional weight loss

  • Fatigue/weakness that interferes with daily activities

  • Yellowing of the eyes or skin

Not all breast cancer survivors have the same chance of recurrence of their cancer. For example, cancers that have spread to the axillary, or underarm, lymph nodes at diagnosis pose a higher risk of recurrence than those that have not spread to axillary lymph nodes. In addition, the timeframe during which recurrence may occur varies among different subtypes of breast cancer. Hormone receptor positive breast cancers (also called Estrogen Receptor or Progesterone Receptor positive) can recur many years or even decades later. Breast cancers that are hormone receptor negative are unlikely to recur after about five years. It is important to be informed about the specifics of your breast cancer and its treatment, and your physicians should be able to provide you with written copies of this information for your records.

Conclusion

Receiving a diagnosis of breast cancer is a life-changing event. As the most commonly diagnosed cancer in women, with more than 200,000 diagnoses per year in the United States, you are not alone! Early detection and improved treatments have allowed 2.5 million women to describe themselves as survivors. Because there are still 40,000 women who lose their lives to the disease annually in this country, there are always opportunities to get involved in survivor support.

Many survivors enjoy participating in support groups, local walk/run events, and government advocacy. Others have raised funds for research and education/awareness. Opportunities to volunteer are available through organizations such as the American Cancer Society (http://www.cancer.org) and the Susan G. Komen for the Cure Foundation (http://ww5.komen.org/ [5 June 2012]).

Footnotes

1.

This document is FCS8996, one of a series of the Department of Family, Youth and Community Sciences, Florida Cooperative Extension Service, Institute of Food and Agricultural Sciences, University of Florida. Original publication date November 2011. Visit the EDIS website at http://edis.ifas.ufl.edu.

2.

Martina Murphy, M.D., internal medicine resident PGY-3; Karen Daily, D.O., clinical assistant professor, Division of Hematology & Oncology; College of Medicine; University of Florida. Reviewed by Linda B. Bobroff, PhD, and Martha Monroe, PhD, UF/IFAS Extension.

The use of trade names in this publication is solely for the purpose of providing specific information. UF/IFAS does not guarantee or warranty the products named, and references to them in this publication do not signify our approval to the exclusion of other products of suitable composition.


The Institute of Food and Agricultural Sciences (IFAS) is an Equal Opportunity Institution authorized to provide research, educational information and other services only to individuals and institutions that function with non-discrimination with respect to race, creed, color, religion, age, disability, sex, sexual orientation, marital status, national origin, political opinions or affiliations. For more information on obtaining other UF/IFAS Extension publications, contact your county's UF/IFAS Extension office.

U.S. Department of Agriculture, UF/IFAS Extension Service, University of Florida, IFAS, Florida A & M University Cooperative Extension Program, and Boards of County Commissioners Cooperating. Nick T. Place, dean for UF/IFAS Extension.